背景:尽管有关于虐待性头部创伤的诊断和时机的研究,儿科专科医师之间的实践仍然存在差异。
目的:使用婴儿头部损伤的案例,检查儿科专科医师的诊断变异性。次要目标是专家之间的时间可变性,以及虐待儿童儿科医生(CAPs)的诊断和时间变异性。
方法:从儿童虐待儿科招募儿科专科医生,医院医学,急诊医学,重症监护,和神经外科来完成一个研究仪器。如果参与者在其职业生涯中评估了至少1例可能的虐待性头部创伤,则有资格参加该研究。
方法:这种多机构,混合方法研究使用的研究仪器有4例婴儿头部损伤:严重的视网膜出血(RH),质量效应硬膜下出血(SDH),SDH膜形成,还有败血症.大多数CAPs选择的响应是参考,并使用卡方或Fisher精确检验在亚专业和CAPs之间进行比较。Bonferroni校正(p<0.01)用于亚专业比较。
结果:有288名参与者完成了至少1个案例。在所有病例实例中均观察到诊断变异性。医院医学显著减少(34.9%vs.57.9%,p<0.01),急诊医学(28.0%vs.57.9%,p<0.0001),和神经外科(24.0%vs.57.9%,p<0.01)参与者选择了质量效应SDH案例示例的参考响应。所有病例的时间变异性均具有统计学意义(p<0.01)。对于重度RH病例示例,44-64岁的CAPs选择了时间参考响应(p<0.01)。
结论:针对虐待性头部创伤中具有挑战性问题的其他同行评审过程和共识指南可能是有益的。
Although there is research regarding the diagnosis and
timing of abusive head trauma, there remains practice variation among pediatric subspecialists.
To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were
timing variability among subspecialists, and diagnostic and
timing variability among Child Abuse Pediatricians (CAPs).
Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career.
This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher\'s exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons.
There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example.
Timing variability was statistically significant for all
case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for
timing (p < 0.01) for the severe RH
case example.
Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial.